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September 06, 2009

Common sense about swine flu

The flu season has barely begun and yet the panic is already in full swing with 186,933 media stories about H1N1 and 47,159 news stories about the swine flu currently at Google News.* Do you know what is missing among the widespread pandemic alarm in the media and coming from government agencies, pharmaceutical and other stakeholders?

The scientific evidence being reported by medical professionals and in the medical literature.

The September 3 issue of the British Medical Journal published an analysis from MIT (Massachusetts Institute of Technology) about how public health responses to flu pandemics have not followed the scientific evidence and that public strategies, which are based on catastrophic epidemic scenarios, risk doing more harm than good.

BMJ even sent out an EurekaAlert press release — Eureka is the global news service provider of the American Association for the Advancement of Science that goes to mainstream media reporters and freelancers and even makes the original studies available to them free. Usually, stories written for reporters on Eureka are plastered across the media but a diligent search for this one found only three articles even mentioning it on Google News, among more than a quarter million news stories about the flu pandemic.

In the same BMJ issue was a report about physicians in Spain, including the Spanish Medical Association, representing around 200,000 physicians, who’ve launched a country-wide “Common Sense” flu communication initiative called Gripe A— Ante Todo Mucha Calma [“Influenza A, above all, very calm”]. It was endorsed by the Organización Médica Colegial [College Medical Association] and has been praised by the Spanish Minister for Health and Social Policy, Trinidad Jimenez. He described the pandemic of H1N1 mostly as an epidemic of fear caused by a ghost illness being fought by exaggerated responses.

The medical community — seeing the strong disconnect from the information politicians and public officials are giving the public, and the science — has been enthusiastically supportive of Common Sense. As one doctor commented: “With so much media morbid, with so many hoaxes on the net and, above all, with so many interests at stake, it takes a lot of information, education and common sense.”

On September 2nd, forty medical professionals promoting evidence-based medicine also collaborated on an online blog project as part of the Common Sense initiative and simultaneously published the same article explaining the best scientific knowledge about the flu and stressing that there is no evidence to justify alarm.

There was no mention of these medical articles in the Google News, even specifically searching using pertinent search terms. And any mention of the blog project was only found by doing a word search of the participating Spanish medical blogs by name.

Google’s HealthAdvisory Council appears to have determined that mention of these medical articles is not “relevant for you.” Google has become such a transparent social media marketing venue, it’s impossible for those who follow science and research to miss how Google’s search results prioritize what government-private stakeholders want the public to believe, not what people may want or need to know. Consumers searching Google for information, however, are largely oblivious to the degree that Google’s firewall filters their news.

As a continuation of JFS’ swine flu coverage and efforts to offer balance with medical and scientific research that mainstream media ignores, let’s take a look at this issue of BMJ and the articles from MIT and physicians. The MIT article recapped the medical evidence and conclusions of infectious disease experts that has previously been reported at JFS.

From MIT

“Over the past four years, pandemic preparations have focused on responding to worst case scenarios,” wrote Peter Doshi. As a result, government officials have reacted to H1N1 as if it was “an unfolding disaster.” Their measures are alarmist, overly restrictive and unjustified, given what science knows about emerging infections and advanced laboratory surveillance, he explained. Our understanding of epidemics has changed.

Yet, an impression of the “seriousness of the threat” is underlined by officials spending large sums of public money on pandemic preparedness ($7 billion in the United States). And often repeated phrases — such as those by the U.S. Department of Health and Human Services stating “it’s not a question of IF a pandemic will happen, but WHEN” — characterize the next flu pandemic as a high probability event with extremely serious consequences. But the 2009 pandemic “bears little resemblance to the forecasted pandemic,” he pointed out.

“Pandemic A/H1N1 virus is not a new subtype but the same subtype as seasonal [influenza] A/H1N1 that has been circulating since 1977.”

The word “pandemic” doesn’t mean what the general public thinks it does and few people are even aware that the definition has been changed. In declaring a global pandemic of H1N1, the World Health Organization, as well as the U.S. Centers for Disease Control and Prevention and the Public Health Agency of Canada, changed the definition of “pandemic.” This pandemic wouldn’t be a pandemic with the old definition.

For years, Doshi explained, influenza pandemics were defined as occurring when a new influenza virus appears where the human population has no immunity, resulting in epidemics worldwide with enormous numbers of deaths and illness. That phrase was removed from the definition in early May, just after a phase 5 pandemic alert was declared. The definition of pandemic was changed to reflect how widely dispersed a virus has been detected, not how severe the disease. Yet, the response of public officials for what has largely been a clinically mild illness, as well as the impact on society, he wrote, proceeded based on long-standing assumptions of pandemic disaster scenarios.

Even Dr Margaret Chan, Director-General of the World Health Organization, acknowledged at the H1N1 Health Ministers’ meeting in Bangkok, Thailand, on May 8: “H5N1 has conditioned the public to equate an influenza pandemic with very severe disease and high mortality. Such a disease pattern is by no means inevitable during a pandemic. On the contrary, it is exceptional.”

Doshi also explained how laboratory testing is used to drive public fear and create misperceptions of huge increases in the numbers of cases of the disease. “On 26 April, with 20 cases and no deaths in the US, the Department of Health and Human Services declared a nationwide public health emergency. The subsequent increase in laboratory testing was unprecedented.” The week after the emergency was declared, testing increased nearly sevenfold.

Heightened testing and the “seek and ye shall find” phenomena does not mean there is a real increase in the prevalence of a disease, as JFS has explained. But it’s easy to mislead with statistics and create fears and perceptions of deadly epidemics in the minds of the public. People can even be led to fear something less serious than a common cold and the sniffles. As Doshi writes:

The sudden emphasis on laboratory testing for H1N1 in the first weeks of the outbreak, particularly in the US, produced what I call concern bias, in which concern and anxiety may drive events more than the disease itself. Concern bias confounds the interpretation of data in important ways. The rapid increase in virological testing amplified the perceived prevalence of A/H1N1 and simultaneously minimised the role other agents may have played in causing the same symptoms. After the declaration of a public health emergency, the percentage of respiratory specimens testing positive for influenza viruses increased for eight consecutive weeks to a peak of 40%. This increase, however, may only in part reflect a true increase in prevalence of influenza. It may also be due to behavioural changes in the way respiratory specimens were taken, tested, and reported on.

Laboratories were overwhelmed with a large volume of respiratory specimens, often from patients who under ordinary circumstances would not have had a specimen taken (an extension of the "worried well" effect)….The high concern also makes it difficult to determine whether this epidemic revealed itself or whether its presence came to light only because of heightened awareness triggered by official announcements.

Today’s advanced laboratory capabilities also allow us to track epidemics at a level of detail never possible before and media can present a confusing, frightening perspective that exaggerates the severity of the clinical illness and the number of people threatened by it.

The greatest failures of responses to infectious disease epidemics has been in not recognizing that there are four clinical-epidemiological variations to viruses and in not taking responsibility to ensure that the response is matched to be suitable to the virus. A single, one-size-fits-all public health strategy that assumes every epidemic results in widespread catastrophic and deadly disease (type 1) is not appropriate. Some epidemics affect very few people but the infection is serious (type 2), while type 3 affects many people but with mostly mild infections. But most new viruses, he stressed, are not type 1 threats. The 1957 and 1968 pandemics, for instance, went largely unnoticed by most people and the recorded deaths during both pandemics were similar to those seen an ordinary flu season today.

So, we have pandemic preparedness strategies that are based on a catastrophic (type 1) epidemic and which result in public health responses that are improperly calibrated to the threat and risk doing more harm than good. They are also seen as alarmist and erode the public trust.

Common Sense physicians speak out

It was this understanding of the need for more common sense and rational communications to the public about swine flu that led the Spanish physicians and medical professionals to begin their “Common Sense” communication efforts. The information they have been providing could help people around the world understand what the medical evidence actually supports.

For instance, they explain that swine flu produces the very same cold-like symptoms as seasonal flu, people get it the same way as the seasonal flu (from droplets as people cough or sneeze), and that people can help avoid getting sick by following the very same basic recommendations of hand washing, covering their coughs or sneezes, and avoiding contact with sick people. Those quick laboratory tests to see if you have swine flu are accurate only about 35% of the time and are not useful, they explain. They add that despite the scary misinformation, swine is no more dangerous for pregnant women than the seasonal flu: “Being pregnant does not increase the risk of suffering from swine flu.” Ideally, all pregnant women receive good prenatal care and contact their doctor for all infections.

Just because the virus is infectious and spreads easily, however, does not mean that it is more serious. This virus has proven to cause mild or moderate flu and to be less severe than the ordinary seasonal flu. Most people have mild symptoms and will get no benefit from going to the doctor, the physicians stress. Most importantly, the advice for taking care of the swine flu is the same as in all types of colds and flu. Most people can care for themselves at home, just as they would any cold or flu, with keeping themselves hydrated and nourished.

“Previous flu pandemics do not produce high mortality since we have had antibiotics to cure pneumonias which complicate flu,” explained Dr. Juan Gérvas, a general practitioner and public health professor at the School of Medicine at Autonomous University in Madrid. Historically, flu pandemics also do not have “second waves,” he wrote, and if they occur, they are not likely to be more severe. “It’s absurd to panic about swine flu, especially since it won’t cause severe disease in many people. The current WHO messages, which are increasing fear of swine flu is a form of disease mongering.” And the media’s focus on worst case speculations and giving detailed accounts of every case or every death is irresponsible. While keeping death rates low should not be a problem for medical professionals because of the low severity of the virus itself, he wrote, avoiding social chaos “calls for a strong policy of calmness and accurate information for both professionals and the public.”

If you get sick, the physicians repeat the old adage: ‘The flu lasts 7 days with treatment and one week without it.”

Anti-viral medications do not do much to limit the infections and have proven to have very small benefits, and their routine use is not recommended, the doctors advise. “Anti-virus drugs have not proven effective in infections by seasonal flu; at most they decrease symptoms in less than one day. And considering the swine flu, we even lack any probe of efficiency,” they write. The drugs also have side effects and “in previously healthy people the risk of side effect can be bigger than the benefits.” We know nothing about the safety or effectiveness of new vaccinations specifically for swine flu that are not yet on the market.

Finally, they urge that using health care services because of fear about flu symptoms is unwarranted. Just like any illness, those with severe symptoms should see their doctor (such as trouble breathing, chest pain, fainting, sudden worsening of symptoms, or symptoms during more than seven days), as well as children under 6 months or who have trouble breathing or a fever that lasts more than 3 days. But during any flu pandemic, there will still be people who need medical care for serious conditions such as heart attacks, appendicitis, heart failure, diabetes, asthma attack, hip fractures, accidents, etc.

“It is important that patients suffering from swine flu do not panic and overwhelm the system, so hospitals and doctors can continue to treat all patients,” they concluded. That’s why it is essential to keep calm and have common sense and self-control — and that means everyone including “patients, health professionals, decision makers, politicians and the media.”

Given that it’s unlikely the enormous political and financial interests behind flu pandemics will come to a screeching halt, that leaves medical professionals and consumers to be the responsible ones and get the facts, keep calm and practice common sense.